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International Journal of Advances in Psychology Vol. 1 Iss. 3, November 2012 



The Impact of Family on Obsessive 
Compulsive Disorder in Children and 
Adolescents: Development, Maintenance, and 
Family Psychological Treatment 

Martina Smorti 

Faculty of Education, Free University of Bolzano, Bressanone, Italy 
Email: martina.smorti@unibz.it 



Abstract 

It is widely recognized that some parental characteristics 
can influence obsessive compulsive disorders in children 
and adolescents. Family involvement and parental style 
characterized by high expressed emotion, over-protection, 
over-control are associated with the development of 
obsessive compulsive disorders in children. As a 
consequence, family involvement in the treatment of youth 
with obsessive compulsive disorders has been widely 
suggested. Although various forms of family therapy are 
used, cognitive behavioural treatment is widely recognized 
as the first-line treatment of paediatric obsessive compulsive 
disorders. Despite several studies reveal efficacy of family 
therapy, it has been underlined that more than an half of 
children remain symptomatic post-treatment. In order to 
improve treatments for children with obsessive compulsive 
disorders, research has identified personal and familiar 
predictors of response to treatment. The clinical implications 
of these studies are discussed. 

Keywords 

Obsessive Compulsive Disorder; Childhood; Adolescence; Family; 
Psychological Treatment 

Introduction 

Obsessive-compulsive disorder (OCD) is an anxiety 
disorder that involves (a) intrusive, unwanted thoughts, 
ideas, or images that evoke anxiety (obsessions), and (b) 
deliberate behavioural or mental rituals, that serve to 
neutralise anxiety (compulsions) [1]. OCD affects as 
many as 2-3% of children [2, 3] with significant 
functional impairment in a number of critical domains. 
The obsessions and compulsions that characterise OCD 
interfere with social, academic, and family 
environments [4-5] and have negative consequences on 
quality of life [6]. 

Common obsessions in children have themes of 



contamination, aggression (harm or death), symmetry, 
and exactness, while in adolescence, religious and 
sexual obsessions also become common [7]. Common 
compulsive behaviours reported in young people 
include hand washing/cleaning, counting, praying, and 
checking [8]. 

The literature review and discussion in this article 
focuses on the role that parents and family members 
have on OCD in childhood and adolescence. 
Family-based treatments for young people with OCD 
will be also reviewed and their efficacy will be 
discussed. 

Family Factors Associated With Childhood 
Ocd 

Family involvement 

Several authors place great importance on the role of 
the family environment in the development and 
maintenance of OCD [9]. This emphasis is logical 
because the vast majority of children and adolescents 
spend a significant portion of their lives in the 
presence of families. In this context, it has been 
suggested that family members of youth with OCD 
are often involved in the young person's rituals 
[10-12]. The person's obsessive doubts, 
indecisiveness, constant search for reassurance, and 
avoidance behaviours can lead to extreme 
dependence on family members, who usually have to 
assume many of the person's activities, duties, and 
responsibilities [13]. Family participation in the 
child's obsessive-compulsive symptoms is referred to 
as "family involvement" or "family accommodation" 
[10]. Family participation can operate both directly 
(e.g., participation in rituals; interference with or 
intrusion in rituals) and indirectly (e.g., modification 
of the family's lifestyle around the symptoms). Some 



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authors have attempted to describe familiar 
responses to obsessive-compulsive symptoms along 
a continuum ranging from accommodating to 
antagonizing [14]. An accommodating response 
refers to that of those families whose members are 
consistently involved in, and supportive of, their 
child's rituals [15]. The goal of such involvement is 
often to help the person with OCD to reduce distress 
[16]. An antagonistic response instead refers to that 
of families who are critical and hostile towards the 
child's symptoms and who consistently refuse to 
encourage or be involved in the ritualistic behaviour. 
Attempting to stop the child from performing his or 
her ritual and forced traumatic exposure to the 
feared stimulus are examples of antagonistic family 
involvement [14]. Of course there are also situations 
where one parent takes the antagonizing stance and 
the other is accommodating of the symptoms. Even if 
this is a rather simplistic categorization of familial 
responses, one point is clear: regardless of whether 
families reject or accommodate the symptoms, they 
are often inextricably involved in the disorder. 
Moreover, both accommodating and antagonizing 
family responses tend to perpetuate and reinforce 
OCD symptoms, increasing the frequency and/or 
severity of the rituals [16-17]. 

Parenting style 

It is widely recognized that some characteristics of the 
family environment are associated with the 
development of OCD in children. One family factor 
that has been associated with OCD is expressed 
emotion [18-21]. Expressed emotion refers to a family 
environment characterised by hostility, criticism, or 
emotional over-involvement [22]. It has been found 
that high expressed emotion is characteristic of 
families with an OCD child in comparison to families 
with a typically-functioning child [20]. Moreover, high 
expressed emotion is also associated with child OCD 
symptom severity [21] and greater family 
accommodation. Moreover, parental attitudes 
characterized by over-protection, over-control [23], 
low confidence in the child's ability, low reward of 
independence [18], parental blame [24], low 
problem-solving skills, and high parental 
catastrophising behaviour [18-19] are associated with 
OCD in children. On the other hand, low affection [23] 
and low support [25] have been found in parents of 
youth with OCD. These parental attitudes may create 
avoidance, caution, and tearfulness in children and 



thus predispose them to developing obsessive- 
compulsive symptoms [26]. Moreover, factors such as 
high parental anxiety [27] and perceived lack of 
control over external events [28] are also hypothesised 
to be relevant to the exacerbation of OCD in 
childhood. 

Psychological Treatments: The Role Of 
Family 

Consistent with previous considerations, family 
involvement in the treatment of children with OCD 
has been widely suggested [29-31]. In fact, children 
need significant family support in order to address 
OCD symptoms and parents need specific tools (e.g. 
behaviour modification strategies) to help their 
children to implement the treatment program at 
home [32]. Moreover, since high levels of hostility 
and criticism (expressed emotion) have been 
associated with child OCD symptom severity and 
greater family accommodation [21], involving 
parents in child OCD treatments is important for 
three reasons. 

First, because hostility and criticism could result 
from parents' believe that children with OCD could 
control their compulsions [33] and that they tend to 
be manipulative with their obsessions and 
compulsions [34], a family intervention could be 
useful for parents to understand their children's 
problem. Thus, explaining the genesis of the 
behaviors, delineating the boundaries of the disorder 
and attributing mental health symptoms to the 
illness (external attribution) rather than to the patient 
(internal attribution) may help parents have a more 
positive attitude toward OCD symptoms [34] and to 
moderate high expressed emotion [35]. Second, 
including parents directly addresses parents' 
tendency to accommodate their child's OCD 
behaviour [36]. Third, training parents to be coaches 
for their children plays a key role in shaping 
treatment and ensures adherence and motivation 
outside of the treatment session [36]. 

Various forms of family therapy are used in the 
treatment of paediatric OCD. Most interventions 
adopt behavioural therapy, involving exposure to 
feared situations and the prevention of compulsive 
behaviour [37], cognitive therapy, in which intrusive 
thoughts are identified, understood and discussed 
[38-41], and a combination of behavioural and 
cognitive therapy [42-44]. 



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Cognitive-behavioural family therapy for young 
people with OCD is based on the recognition that 
families are so involved in the young person's rituals 
that family relationships are disrupted. Consistent 
with several works, cognitive-behavioural family 
treatment involves the parents, the child and the 
therapist [45-46]. The focus of the treatment is to help 
the family understand how their involvement can 
maintain the disorder and then help them withdraw 
from the compulsions. Although the aim of 
cognitive-behavioural family therapy is to improve 
family relationships, the focus is more on reducing 
the affected individual's obsessive-compulsive 
symptoms [47]. 

Few treatment interventions have adopted systemic 
family therapy approaches for paediatric OCD cases. 
General systems theory assumes that living 
organisms can be seen as a group of elements in 
interaction with one another, forming stability over 
time, with boundaries within itself and between itself 
and the environment. The system has properties such 
as wholeness and non-summativity (the whole is 
greater than the sum of its parts), feedback 
incorporated to maintain the function of the system 
(homeostasis), and equifinality (the same endpoints 
can be reached by different stimuli (the organisation 
of the system is more significant in determining 
reactions) [48]. 

In OCD treatment, systemic family therapy tends to 
focus on the meaning of the symptoms within the 
family unit. In this approach, family treatment 
involves the parents, the OCD child, siblings and the 
therapist [49]. The therapist tends to see OCD 
symptoms as a sign that the family unit is stressed, 
leading to difficult, unspoken emotions between 
family members [47]. These interventions aim at 
altering the family system, improving relationships, 
and increasing communication and emotional 
expression amongst family members. While these 
family interventions have included procedures 
designed to alter family dynamics directly [50-51], 
they have often also included behavioural 
components [51-52]. Other interventions have 
adopted systemic family therapy approaches where 
OCD has been considered to represent a metaphor 
for family dysfunction [51-52]. 

Techniques used in family therapy for OCD children 

Cognitive behavioural therapy is widely recognized 
as the first-line treatment for young people with 



OCD [31, 53-55]. 

It has been suggested that involving family in 
cognitive behavioural therapy allows children to 
enter anxiety-provoking situations in a planned way 
and to manage these through the use of coping skills 
and parental support [56]. 

1) In cognitive-behavioural family therapy both 
parents and children attend separate group sessions 
and some concurrent family therapy sessions [57]. 
Cognitive-behavioural family therapy offered to 
individuals or groups has been found to be equally 
effective [31]. The main components of cognitive- 
behavioural family therapy are: 

2) Psychoeducation. This typically includes 
discussion of the nature of the disorder, its causes, 
prevalence, prognosis, maintenance factors, and 
effective treatments for it. It is important "to 
externalise the problem", clarifying to both family 
and the person with the disorder that OCD is a 
medical illness which is distinct from the youngster's 
core identity [58]. Externalising OCD in this way 
helps the child and family to feel empowered and to 
decrease anxiety [59] and assists parents to reduce 
hostile attitudes toward their child. It has been found 
that relatives who believed that people with OCD 
could control their compulsions were likely to be 
more hostile and critical than those who considered 
the OCD symptoms to be an illness [33]. 
Psychoeducation also aims to clarify that both the 
child and family already have some influence over 
this disorder [58]. So the therapist, child, and family 
become members of the same team with a unified 
goal of helping the child eliminate OCD from his or 
her life [58]. 

3) Parenting tools. Parents are provided with a set of 
tools used throughout treatment to increase the 
child's motivation for change and to more effectively 
manage their child's OCD symptoms. The main 
parenting tools include differential attention, 
modeling, and scaffolding [60]. For differential 
attention the therapist explains to the parents that 
they can use their attention to change their child's 
behaviour. So, they can give attention to behaviour 
they want to see and withhold attention from the 
behaviour they do not want to see [32]. For the 
modeling, the therapist explains how parents can 
positively reinforce the child's behaviour by giving 
positive attention and tangible rewards [60]. For the 
scaffolding, the therapist explains how parents can 
guide their child's emotion regulation in response to 



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an event so that the child internalises his or her 
response through self-regulation [32]. 

3) Exposure and response prevention. This is directed at 
the young person with OCD and aims to get parents 
and children to actively work together. This 
treatment has been designed to expose the individual 
to provocative stimuli (e.g., touching a 
"contaminated" object) while simultaneously 
refraining from compulsions (e.g., hand washing) [29] 
and it has been found to be an effective treatment for 
children with OCD [4, 61]. In exposure and response 
prevention, firstly a hierarchy of symptoms is created. 
A hierarchy of rituals can be constructed which 
includes a rating for the degree of anxiety 
experienced by the youth when he or she refrains 
from carrying them out. The gradual nature of this 
approach allows the child or adolescent to increase 
his or her anxiety management skills [62]. 

4) Homework. This is given to the person with OCD at 
each treatment session. Tasks to perform at home 
relate to one or more of the items on the hierarchy, 
and usually begin with the lowest rated item. The 
purpose of this homework is for the child with OCD 
to practise mastery over the symptoms. The therapist 
must explain these homework assignments carefully 
to the child, emphasizing the importance of mastery 
over OCD each and every day [63] . In family therapy 
parents are asked to tolerate their own distress while 
they assist their children during upsetting exposure 
exercises and homework tasks [36]. Parents are also 
asked to monitor their child's behaviour and to 
encourage self-exposure in a noncritical manner [64]. 
For example, if a child washes his or her hands 
several times per day, reducing the number of 
handwashings per day could be part of a homework 
assignment. Parents must then support the child in 
postponing his or her handwashing and at the same 
time, they must increase the length of the 
compulsion- free intervals [63]. 

5) Anxiety management training. For children with 
predominantly internalising symptoms, treatment 
often includes anxiety management training. This 
therapeutic "tool", which includes progressive 
muscle relaxation, diaphragmatic breathing, and 
coping imagery [65], allows the child to better 
manage the changes in affect that occur before, 
during, and after exposure and response prevention 
[66]. In family intervention, anxiety management 
training involves teaching parenting skills for 
managing child distress and avoidance, parenting 



skills for parents to manage their own anxiety, and 
parental communication and problem-solving skills 
[67]. 

While engaging family members in OCD treatment 
for young people has been broadly suggested as 
being important, only a few interventions pay 
particular attention to family accommodation [68-69]. 
In these interventions, antagonistic or 
accommodating behaviours were firstly identified 
and discussed. Then, if a family member was 
assessed as being too accommodating, that 
individual received homework assignments related 
to reducing the accommodation, such as working 
with the young person to come up with a plan to 
begin disengaging from help during a compulsion. In 
the case of an antagonizing family member, he or she 
received training in methods to disengage from the 
conflict [68-69]. 

Several studies have been conducted to evaluate the 
efficacy of cognitive-behavioural family therapy. 
These investigations have revealed that family 
therapy significantly decreases symptom severity, as 
well as symptom-related distress and impairment, 
and treatment gains have been maintained over time 
[31, 44, 53, 69]. However, despite its effectiveness, 
treatment response is less than perfect, with a 
substantial percentage (more than fifty per cent) of 
treatment recipients remaining symptomatic 
post- treatment [30]. 

Predictors Of Ocd Treatment Outcome 

In order to improve treatments for children with OCD, 
several studies have tried to identify predictors of 
treatment response in paediatric OCD or, in contrast, 
predictors of non response to treatment [70-71]. 
Recently, two interesting literature reviews focused on 
predictors of treatment response in young people with 
OCD [70-71]. Results suggested that parental high 
expressed emotion, hostile criticism, and emotional 
over-involvement [72-73] are associated with greater 
dropout and/or poor cognitive behavioural treatment 
outcome for people with OCD. 

With regard to expressed emotion, it has been 
suggested that parents' criticism does not appear to be 
problematic if it is not hostile. In fact, while criticism 
of OCD behaviours may serve as a motivator for 
people to seek therapy and work on their problem 
during treatment, hostile criticism appears to make it 
difficult for them to continue in treatment and to 
benefit from it [74]. 



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Other studies have reported that high family 
accommodation was associated with a worse response 
to behavioural therapy in children with OCD [68, 74]. 
In addition, decreases in family accommodation 
during treatment predicted treatment outcome: 
helping family members disengage from compulsions 
and resist accommodation during behavioural 
therapy appeared to improve OCD treatment 
outcomes [68-69]. 

It has also been highlighted that greater obsessive 
compulsive symptom severity [70-71] and a comorbid 
diagnosis of a personality disorder [71] consistently 
predict poorer treatment responses for these 
individuals. 

Finally it has been displayed that the therapeutic 
alliance is a reliable predictors of treatment response: 
both child-therapist and parent-therapist therapeutic 
alliance, indeed, have been indicated as significant 
predictor of subsequent change in OCD symptoms 
treatment outcome [75]. 

Conclusions 

The studies on OCD in young patients in the present 
review indicate the reinforcing role of both expressed 
emotion [18, 74], that is a parental attitude 
characterised by hostility and criticism [22], and 
family involvement in the individual's rituals, either 
in an accommodating or antagonizing manner [10, 11, 
14]. 

Given the central role of family in the development 
and maintenance of OCD in children and adolescents, 
including family members in the young person's 
therapy may be advantageous in order to educate and 
advise parents about OCD symptoms and how to 
respond to their child [29- 31]. Moreover, training 
parents to be coaches for their children plays a key 
role in shaping treatment and ensures children's 
adherence to treatment and motivation outside of the 
treatment session [36]. 

Several family-based treatments have been proposed 
for children with OCD. Most of these interventions 
have adopted cognitive-behavioural family therapy 
[42-43] while a few of these have used systemic family 
therapy [50-51]. 

Although most studies on OCD treatments emphasise 
improvements in young people's symptoms [31, 53, 
69], some of them point out methodological flaws in 
these interventions and these reveal that treatment 
efficacy is less than perfect with more than an half of 



children remaining symptomatic post-intervention 
[30]. 

All these concerns suggest to redefine our 
methodological approach to family therapy 
identifying the best method to achieve the greatest 
efficacy. The first issue concern therapy orientation. 
As previous mentioned, cognitive behavioural 
therapy, as the first-line of treatment for OCD 
paediatric patients, it is well structured and wide 
adopted. However, although the focus of the 
treatment is to the family, it usually involves the 
parents, the child and the therapist but not siblings 
[45-46]. On the other hand systemic therapy involves 
parents, paediatric patient, siblings and the therapist 
[49] but it has been less used in OCD treatment. Thus, 
it could be useful adopt cognitive behavioural family 
therapy as the first line of treatment but including 
siblings as suggested by Barrett [31]. 

The second issue concerns family factors that should 
be taken into consideration and managed in planning 
a family intervention for children with OCD. In this 
context studies on predictors of treatment response in 
young people with OCD are crucial [70-71]. 

Parental high expressed emotion, hostile criticism, 
and emotional overinvolvement [72-73] should be 
considered as predictors of treatment dropout. For 
this reason Steketee and colleagues [22] have 
suggested assessment and intervention strategies for 
reducing criticism and hostility during psychological 
treatment. Thornicroft, Colson and Marks [64] 
reported a treatment program where relatives were 
asked to monitor their child's behaviour and to 
encourage his or her self-exposure in a noncritical 
environment. In this context, "externalising the 
problem" during the psychoeducational treatment 
component helps parents to become less hostile and 
critical toward the young person with OCD [33]. 

Another relevant family factor to take into 
consideration is family accommodation [68, 74]. As 
was previously mentioned, some strategies could be 
useful for managing family accommodation in 
family-based interventions for OCD young cases. 
Some of these are specifically focused on family 
accommodation [68-69], others have been designed to 
alter family dynamics [50-51], while others, moving 
from family-based treatment, can help parents to 
avoid inadvertent reinforcement of children's 
compulsive rituals [56]. 



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Lastly the timing of the treatment seems to be another 
crucial variable. The findings from previous studies 
have indicated that symptom severity and the 
presence of a comorbid personality disorder should be 
taken into consideration in planning OCD treatment 
[70-71]. These data emphasize the importance of 
treating OCD as soon as possible. In fact, if left 
untreated, or if inadequately treated, there is an 
increased likelihood that the OCD in these young 
children will extend into their adulthood [60], thereby 
enhancing the severity of their obsessive compulsive 
symptoms [76]. Moreover, leaving OCD untreated 
increases the risk of comorbidity in adulthood [77]. 

However, as Maskey [34] noted, despite the 
considerable distress and disability accompanying 
OCD, most parents do not recognize the nature of the 
disorder. As such, it is often unrecognised and 
undertreated. Family members need to be able to 
recognise various presentations of OCD. To assist 
with this, health promotion activities focused on OCD 
could be carried out both in schools and at the public 
health service. In this way family members could be 
informed about OCD and refer their children and 
adolescents to a specialist without delay. 

Finally, in order to improve OCD interventions for 
youth, more studies on predictors of OCD treatment 
response are crucial since these can suggest factors 
that should be taken into consideration in planning 
interventions for children with OCD. 

ACKNOWLEDGEMENTS 

We would like to thank Sarah L. Barker for her review 
of the English translation. 

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Author Introduction 




Martina Smorti is research Professor 
of Developmental Psychology at the 
Faculty of Education of the Free 
University of Bozen. Her research 
interests focus on adolescence, risk 
behaviours and health psychology. 



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